Code of Conduct - UCHealth · No. Our actions must always be guided by our Standards of Excellence. We serve others with courtesy, compassion and sensitivity. Patients are often frightened,

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Code of Conduct

Dear UCHealth Team Member,

UCHealth takes great pride in caring for each and every patient who walks through our doors. Our mission is to improve lives, and we are committed to providing the quality of patient care necessary to accomplish our mission. We are equally committed to always doing what is right and ethical on behalf of patients, their families and each other. For this reason, we ask that everyone team member (employee, physician, vendor, contractor, student and volunteer) within UCHealth make a personal commitment to follow UCHealth’s Code of Conduct.

The Code of Conduct serves as a cultural compass for everyone who interacts with UCHealth. It provides guidance to ensure that our work is accomplished in a legal, honest and ethical manner, and it demonstrates our integrity as an organization as we strive to care for our patients and move from health care to health.

Thank you for your ongoing support of our mission, vision and values, and our commitment to making the right choices.

Sincerely,

Liz ConcordiaPresident and CEO, UCHealth

ContentsMission. Vision. Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Standards of Excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

UCHealth leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Commitment to the law and ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Patient rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Ethical conduct and compliance in the health care settingHealth Insurance Portability and Accountability Act of 1996 (HIPAA) . . . . . . . . . . . . . . . . . . . . 8Emergency Medical Treatment and Active Labor Act (EMTALA) . . . . . . . . . . . . . . . . . . . . . . . 10Advance directives and health care decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Anti-kickback and Stark. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Compliance with federal health programs (Medicare, Medicaid, etc.) . . . . . . . . . . . . . . . . . . 16Documentation standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Accuracy in records, coding and billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Expense reporting and payroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Computer system and email usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Ethical conduct and compliance in business relationshipsIntellectual property, patents and copyrights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Gifts, gratuities and entertainment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Contractor relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Community activity: Participation on community boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Political activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Tax-exempt status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Employment laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Workplace environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Medical staff compliance and relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Drug- and alcohol-free workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Environmental health and safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Marketing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Social media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Interaction with the government. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Getting help and reporting violations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34How to report a concern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Accessing health system policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Compliance Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

Compliance Department phone numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

HR Service Center phone numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

INTEGRITY HELPLINE: 1.855.824.6287 (Toll Free) 32 UCHealth Code of Conduct

I N T H E H E A LT H C A R E S E T T I N G I N B U S I N E S S R E L AT I O N S H I P S

Mission.We improve lives.In big ways through learning, healing and discovery.In small, personal ways through human connection.But in all ways, we improve lives.

Standards of Excellence.Service:• I am here to serve my customers. This means prompt, friendly and quality service.• I promptly respond to patient requests, phone calls and customer needs.• I communicate in a respectful and professional manner. Nonverbal communication is as important as what I say.• I anticipate patients’ and others’ needs, working to prevent problems and remove barriers.• I communicate frequently about how long a patient, visitor or colleague may expect to wait. I provide

regular updates.• I walk guests to their destination and seek out those who look lost.

Quality:• I seek to understand and improve core measures, quality metrics, best practices, patient satisfaction measures

and employee engagement measures.• I respect the confidentiality of patients and colleagues.• I report concerns and take appropriate actions to eliminate patient, visitor and/or employee safety hazards.• I identify opportunities and solutions for service and safety improvements in my work area and assume

accountability for our success.• I keep the facility and my work area neat, clean, presentable, uncluttered and safe.• I will take appropriate action when public areas do not meet these standards.

Team:• I listen to understand and respond in a compassionate manner.• I encourage my colleagues and offer words of praise for excellent work.• I partner with my colleagues to manage the workflow of my team and willingly pitch in to help others.• I help new or less experienced colleagues feel welcome.• I thank others for their time and efforts.

Personal:• I take responsibility for my attitude and actions. I treat others with dignity and respect; rudeness is

not acceptable.• I am supportive and flexible when change occurs.• I consistently carry out my work duties to the best of my ability, skills and training, understanding that my work

makes a difference in the care of our patients.• I deal with conflict in a constructive manner and welcome personal feedback to improve performance

and relationships.• I look for opportunities to further my learning.• I do the right thing because it is the right thing to do, whether anyone is watching or not.• I take responsibility to use UCHealth resources appropriately.• I take steps to maintain personal health and wellness

Communication:• I maintain a positive image and follow the UCHealth dress code. I wear my badge so it is easily read by patients,

visitors and colleagues. Any time I am in uniform or have my badge on, I represent UCHealth in a positive light.• I show respect to all members of the UCHealth team: volunteers, employees, managers, medical staff,

students and others.• Before I speak, I consider who might be listening and what is appropriate in that situation.• I keep current on organizational information.

Vision.From health care to health.

Values.Patients firstIntegrityExcellence

Why are the Standards of Excellence important?

We believe that teamwork, service and communication are at the core of our organization’s commitment to delivering quality patient care. The Standards of Excellence were developed to reflect UCHealth’s commitment to service excellence. By making an official commitment to practice these standards, we reinforce them, acknowledge that they are expected behaviors and encourage UCHealth team members to practice them diligently.

How will I be assessed in my performance review?

Every year you will be assessed on how well you demonstrate our Standards of Excellence and corresponding values through your work. You will set individual goals to support our strategic objectives.

We had a patient get very stressed the other night and he took his frustrations out on the staff. I had to yell loudly at him in order to bring the situation back under control. Under the circumstances, this is normal, right?

No. Our actions must always be guided by our Standards of Excellence. We serve others with courtesy, compassion and sensitivity. Patients are often frightened, nervous and stressed, and it is our duty to respond with compassionate care to every patient in every situation.

Q&A54



UCHealth leadership.We expect UCHealth leaders to model ethical and compliant behavior. Leaders must help their teams comply with the law, regulations and health system policies. Leaders must also make sure that their teams have the resources to resolve ethical issues. It is the leaders’ responsibility to promote a culture that encourages team members to raise concerns without the fear of punishment.

Commitment to the law and ethics.Government regulations for health care organizations, such as those related to Medicare and Medicaid, are complex. However, following these regulations is critical to UCHealth’s continued growth and success. UCHealth strives to obey the law and to make business decisions that reflect its values. UCHealth, supported by its Chief Executive Officer, is an affirmative action/equal opportunity employer and recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity offer UCHealth. No team member or applicant shall be discriminated against in any terms, conditions or privileges of employment.

Patient rights.UCHealth is committed to caring for its patients in a comfortable manner with dignity and respect. Some of our patients’ rights include:

• The right to express spiritual beliefs and cultural practices as long as those expressions do not harm or interfere with medical treatment.

• The right to expect that communications and records related to medical care will be treated as confidential, except where disclosure is permitted or required by law.

• The right to receive clear, concise explanations of care and proposed treatments, including possible benefits, risks, recovery expectations and alternate treatments.

• The right to receive care in an environment in which caregivers respect diversity.

• The right to receive care based on medical need rather than financial resources.

• The right to receive care in an environment that does not exclude, deny benefits to or otherwise discriminate against any person on the basis of race, color, national origin, language, culture, ethnicity, age, religion, sex, mental or physical disability, sexual orientation, gender expression, gender identity, veteran status, socioeconomic status or any other characteristic prohibited by federal, state or local law in admission to, participation in or receipt of the services and benefits under any of its programs and activities.

How do I know if my conduct is ethical?

If you are worried about your actions being discovered, feel a sense of uneasiness about what you are doing, or feel the need to rationalize your activities (such as believing “everybody does it”), take the time to reconsider your actions. Stop, step back and consider what you are doing. Consult a manager for advice and change your behavior if appropriate.

There are so many changes to laws and regulations. How can I be sure that my department knows about the changes and is in compliance with all of these laws?

While the number of changes in the law may be overwhelming, we have a responsibility to understand and obey them. Every department leader is responsible for ensuring that all of his/her staff are aware, understand and follow relevant laws and regulations. As a UCHealth team member, you are responsible for attending meetings and reading any materials provided to ensure that you understand and comply with applicable laws. If you have questions concerning a law or regulation or whether it applies to you, please speak with your supervisor or manager.

Q&A76



Health Insurance Portability and Accountability Act of 1996 (HIPAA).HIPAA guides health care providers to protect patients’ rights to privacy and security of their health information.

UCHealth team members safeguard the confidentiality of protected health information (PHI) in computer systems as well as paper records. When we discuss patient care, we identify appropriate places to have the discussion and speak in reasonable volumes to limit any inadvertent disclosure of PHI. We never access or discuss a patient’s treatment or personal information outside of work, and we only discuss a patient’s protected health information with people who have a need to know.

Some health information has additional protection under federal and state law. This includes drug- and alcohol-abuse treatment information, HIV test results, mental-health information and genetic testing results.

I want to find out when my coworker’s birthday is and I know he has been a patient recently. Is it okay to look it up in our electronic health record?

No. It is never appropriate to access a patient’s medical record for personal reasons. Patient information should only be accessed, used or disclosed for treatment, payment or health care operations purposes.

Ethan notices a few people in his work area who routinely fail to log off, especially when they’re using the shared computers. The next person uses the computer under the previous person’s ID. Ethan recognizes that most of his coworkers are authorized to access PHI and have the same computer access permissions. He also knows that it can take a minute or two to log on, time that adds up over a fast-paced day. He’s tempted to report this because he knows this behavior is a policy violation. At the same time, he doesn’t want to get his coworkers in trouble and he feels he might be perceived as petty. Is Ethan’s concern warranted and should he act on it?

Ethan is right to be bothered by this behavior. Despite the time savings, failure to log off and/or use of someone else’s access are both violations of UCHealth policies and HIPAA privacy and security rules. Failure to report these concerns is subject to disciplinary action. Leaving a computer logged on and unattended creates several risks. First, someone who is not authorized to access PHI could access patient records through the logged-on workstation. Second, someone who is otherwise authorized to access PHI could use the logged-on workstation to snoop on selected patients (VIPs, friends, etc.) for personal, not professional, reasons, knowing that the record accesses would not be associated with the snooper’s login. Both of these scenarios would be privacy violations. Therefore, Ethan should report these failures to log off. In fact, with the HITECH Act breach notification rule, members of the workforce are responsible for reporting anything that could be, or could lead to, a privacy or security violation. This is for the benefit of patients and the organization, therefore Ethan should not hesitate to report this behavior.

Q&A98



Emergency Medical Treatment and Active Labor Act (EMTALA).Our dedicated emergency departments will treat anyone with an emergency medical condition. This includes providing our patients with a medical screening exam, stabilizing our patients and appropriately transferring or discharging our patients in accordance with the Emergency Medical Treatment & Active Labor Act, passed as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. If an emergency medical condition exists, treatment must be provided by qualified personnel. If the hospital does not have the capability to treat the emergency medical condition, an appropriate transfer of the patient to another hospital must be done. UCHealth will not delay screening or treatment based on a patient’s ability to pay.

Advance directives and health care decisions.During admission, UCHealth staff and physicians will advise patients of their rights in makinghealth care decisions. This includes the right to accept or refuse medical treatment and have advance directives (e.g., CPR Directive, Do Not Resuscitate, Living Will, etc.). This information is governed by ethical and legal rules.

It will be noted in the medical record whether a patient has an advance directive, including the location of the directive and its provisions, if known. Oral instructions will also be noted in the record. A reasonable effort should be made to obtain a copy of advance directives to be placed in the medical record.

UCHealth will provide the forms to patients upon request and direct patients to resources if they need assistance completing the forms. We do not discriminate against patients based on whether they have advance directives. It is vital to follow the law and health system policies related to advance directives and right-to-die issues.

John comes to the emergency department (ED) with a laceration. The ED is very busy and the triage nurse thinks he would get faster treatment if he went to the urgent care center down the street. Is it acceptable to send him to urgent care so ED staff can concentrate on treating more urgent conditions?

No. EMTALA requires that an individual who comes to an emergency department with an emergency medical condition receives a medical screening examination. If an emergency medical condition is diagnosed, the hospital must either treat and stabilize the patient or transfer the patient in accordance with specific requirements. It is UCHealth’s policy to have the screening done and documented by an emergency department provider (not a triage nurse).

A 19-year-old patient has an advance directive that requests no CPR be performed in the event that his heart would stop and he would stop breathing. I don’t feel comfortable with this. What would happen if I did CPR anyway?

Disregarding an advance directive is a violation of a patient’s rights. An advance directive is a legally-binding document. If this patient is an inpatient, he may very well have a Do Not Resuscitate (DNR) order in place, in which case you would also be disregarding a physician’s order. If you have concerns that you will not be able to carry out the patient’s advance directive, contact your supervisor.

Q&A1110



Research.All research, investigations and clinical trials conducted within the UCHealth system are subject to high ethical standards and must comply with federal and state laws.

UCHealth does not tolerate research misconduct. Research misconduct includes fabrication or falsification of data, research procedures or data analysis; destruction of data for fraudulent purposes; plagiarism; abuse of confidentiality; or other fraudulent actions in proposing, performing, reviewing or reporting the results of research or other scholarly activities.

UCHealth protects all patients and respects their rights during research, investigations and clinical trials. All individuals asked to participate in a clinical trial or research project are given a full explanation of the risks, expected benefits and alternatives to volunteering for a clinical trial during their consent process.

An individual’s refusal to participate in a research study will not compromise his/her access to services. Any person engaging in human subject research at an institution within UCHealth must obtain Institutional Review Board (IRB) approval and facility approval prior to the research taking place. Every researcher must follow federal regulations and UCHealth policies related to research.

Researchers using investigational drugs in their studies need to partner with Pharmacy to ensure that applicable policies and procedures are followed and regulatory requirements are met.

All principal investigators must have the appropriate institutional approval at their location if they plan on conducting research studies on patients or employees on the premises of a UCHealth institution. If you need further information, please contact Research Administration at 720.848.7847.

I am working on a project, but do not think that it is really research. How can this be determined?

Only the IRB can determine whether a protocol is exempt from IRB oversight. The regulations define a human subject as a living individual about whom an investigator (provider, staff or student) obtains data either through intervention or interaction with the individual, or through identifiable private information (e.g., school transcripts or medical records). All protocols involving human subject research must be reviewed and approved by the IRB prior to starting any research activities.

Q&A1312



Anti-kickback and Stark.UCHealth team members must never offer or take compensation of any kind for patient referrals or the maintenance of vendor relationships. Physicians may not refer patients to entities with which they or their families have a financial relationship, unless the financial arrangement is one of the types permitted by law. One exception to Stark is non-monetary compensation. Non-monetary compensation is compensation in the form of items or services that does not exceed a specific dollar amount per year. Team members must strictly follow our organization’s policies when being offered non-monetary compensation or other incidental benefits to themselves or their immediate family members.

Anti-kickback, Stark and non-monetary compensation laws and regulations are very complicated. They often require interpretation by Compliance and/or Legal. If you face a situation that may violate these laws, contact the Compliance Department.

Dr. Freebie promises the hospital five admissions per week in exchange for a nurse to work in his clinic 20 hours per week for no charge. Is this agreement legal?

No. Providers should avoid giving or accepting anything of value in exchange for referrals. If Dr. Freebie would otherwise have to pay the expenses for a nurse to work in his office and the hospital provides it for free, this would be considered a benefit to the doctor. A promise of patient admissions to another entity in exchange for a benefit and/or compensation is both illegal and unethical.

I would like to give Dr. Jones a gift card to thank him for all of his hard work this year on a quality project. Is this allowed?

No. Gifts in the form of monetary compensation (cash or cash equivalents such as gifts cards) are not allowed. Physicians may receive up to a certain amount in non-monetary gifts or compensation such as tickets to a sporting event, a golf shirt or a lab coat.

Each hospital has a designated individual that keeps a log of all non-monetary gifts given to physicians (or their offices). Before you decide to give a gift to a physician, you must check with Provider Relations to ensure you do not exceed the non-monetary limit for the year. Once the annual limit has been reached, no gifts can be given to or accepted by that physician. Violations of this rule can trigger problems for both the giver (i.e., the hospital) and the receiver (i.e., the physician).

I was offered a $100 gift certificate from a drug representative as a “thank you” for connecting him with the physicians and having his drug prescribed on a regular basis. Am I allowed to accept the gift card?

No. It is never appropriate to accept cash gifts (including cash equivalents) from anyone. It is also not acceptable to receive gifts of any kind for the purpose of influencing a decision. You may offer the drug representative the alternative of contacting your hospital's foundation to make a charitable donation.

A vendor has offered to provide free equipment to UCHealth if we buy a certain number of catheters. Is UCHealth permitted to accept that vendor’s offer?

It depends. If you receive an offer from a vendor to provide free services or equipment, discounts or other incentives, contact Supply Chain to determine if it is appropriate to accept the terms offered. Additionally, contact the Compliance Department when you receive an offer for a tying arrangement. A tying arrangement is when a vendor will sell or lease something (e.g., a service, product or space) only if the buying entity will purchase or lease another service, product or space from them.

Q&A1514



Compliance with federal health programs (Medicare, Medicaid, etc.).UCHealth provides services governed by federal, state and local laws and regulations. Practices prohibited by these laws and regulations include: filing of false claims, illegal patient referrals, providing medically unnecessary services, violating the Medicare Conditions of Participationand many others.

Documentation standards.A key part of our ethical and professional principles is documentation. Each team member is responsible for creating and maintaining accurate, complete and timely patient-care records. Each team member must ensure that medical records do not contain false or misleading information and that they meet the requirements of all laws, regulations, Joint Commission standards and health system and hospital policies and procedures, including the medical staff bylaws.

Accuracy in records, coding and billing.We are committed to accurate record-keeping, coding, billing and claims submission. There arenumerous laws and regulations that govern how we maintain records and bill for our services.

The federal False Claims Act (31 USC § 3729-3733) makes it a crime to knowingly make a false record or file a false claim with the government for payment. “Knowingly” is defined as

“deliberate or reckless ignorance of facts that make a claim false.”

Entities and physicians within UCHealth will only bill and submit claims for services that are actually provided and medically necessary. If we make an error in a bill or claim, we will correct the problem by taking one or more of the following steps:

• Refund overpayments or payments made in error.• Resubmit claims.• Provide additional team training.• Contact government authorities.• Create new or revised policies and procedures.• Discipline staff.

Federal penalties for violations of the False Claims Act can be up to three times the value of the false claim, plus fines. Individuals who report violations of the Act and/or possible false claims submitted by their employers are protected under the Act from being fired, demoted, threatened or harassed by their employers.

UCHealth will conduct ongoing reviews of coding and billing practices of its member institutions and physicians to ensure accuracy in record-keeping, coding and billing and claims submission.

A patient is upset because his insurance will not pay for his routine physical. He tells the receptionist, “If you just change the code to ‘high blood pressure’ my insurance will pay it.” Should I change it so the claim gets paid by insurance?

No. If his visit was for a routine physical, it would be fraudulent to change a code for the sole purpose of collecting a payment. Physician documentation for the patient visit must match the diagnosis code so that an accurate claim will be submitted to insurance for payment.

I have a concern that one of the billing staff in my area is not complying with established billing guidelines. Should I report this to my supervisor or should I wait to see if the errors are discovered later?

You should report this to your supervisor or to the Integrity Helpline if you wish to remain anonymous. The issue will be researched and the situation handled appropriately. It is important that all billing guidelines are followed. The situation you observed may or may not be intentional. We have a non-retaliation policy that will protect you in reporting your concerns.

Q&A1716



Expense reporting and payroll.UCHealth team members who use the time and attendance system and submit expense reports must do so completely, accurately, and on time. When submitting payroll or expenses, you are attesting that your time and expenses were for legitimate business on behalf of UCHealth. Contact HR with questions on payroll and expense reimbursement.

Your supervisor or manager’s signature on a payroll record or expense report confirms that it has been reviewed. It also confirms that the reported hours or expenses have been verified and correctly allocated.

Computer system and email usage.The following principles apply to all of UCHealth computers and systems:

• All computers, software and related systems are company property and should be used for business purposes.

• Use computers and systems in an effective, ethical and lawful manner. User accounts may be audited.

• Use only computers and systems you are authorized to use, whether they are at a UCHealth location or another location tied to UCHealth through a network.

• Take all reasonable steps to protect the integrity and privacy of UCHealth computers, systems, software and information and data. In particular, users must not share their access codes, account numbers, passwords or other authorizations with others.

• Using copyrighted material (including software or data) in any situation (including conferences and legal proceedings) without the copyright owner’s authorization is prohibited.

• Follow the health system and institution policies for email, internet, social media and other computer use.

• Respect the privacy of others, including in email, computer files and data transmission.

• Refrain from using UCHealth computers for any unauthorized activities or illegal purposes.

Team members should refer to the UCHealth and institutional policies for a full outline of computer system and email usage policies. Inappropriate uses included (but are not limited to):

• Changing or destroying data owned by others.

• Interfering with valid access to a computer or system.

• Harassing computer users at UCHealth.

• Attempting to discover or change passwords.

• Threatening computer-related security systems at UCHealth.

I routinely travel between facility locations. Can I submit mileage to and from work for reimbursement? I have let everyone in my department know that this is the correct policy but I don’t remember what exactly we can claim?

If you have questions about submitting mileage for travel between facility locations, refer to the UCHealth Travel Reimbursement policy.

I have some items I would like to sell. Is it okay for me to send a group email using my work email account to other UCHealth team members to let them know what I have available?

No. See the UCHealth policy and procedure around Solicitation and Distribution for guidance.

Q&A1918



Intellectual property, patents and copyrights.During the course of your job, you may have the opportunity to develop or design proprietaryinformation including:

• New trade secrets• Procedures• Equipment• Know-how• Research• Products• Services• Customer lists

Whether expressed orally or in writing, these products and information are considered intellectual property. If you are a University of Colorado Hospital Authority employee using company materials on company time, any new development, whether or not it is eligible for patent or copyright, is the property of the company. By signing the Code of Conduct, you agree that any intellectual property is the property of UCHealth or UCHealth’s member entities. In addition, you agree not to use or disclose any proprietary information or anything related to such information during employment or after termination, without the prior written consent of an officer of UCHealth, except as may be necessary and appropriate in the ordinary course of performing your duties.

If you are an employee of University of Colorado Hospital Authority, you agree that all original works of authorship, including without limitation, text, artwork and computer software, made solely or jointly with others within the scope of and during your employment, are “works made for hire” as that term is used in the United States Copyright Act of 1976, as amended.

It is not the intent of this section to change the relationship between author or creator and UCHealth that has existed through the years in relation to copyright ownership of scholarly works.Copyright laws are relevant to our workforce in two different ways:

1. Copyright infringement occurs when you copy an author’s protected work without his/her consent.

2. Copyright protection is needed when you want to protect or copyright your own work. Except as permitted by law, you will not reproduce or use any copyrighted materials without the express permission of the copyright holder, unless licensed under an agreement. Copyrights apply to such things as articles, photographs, books, movies, computer software and advertising. The unauthorized copying and reproduction of any copyrighted materials is not allowed. It is your responsibility to obtain permission to reproduce copyrighted materials prior to reproduction.

• Finances• Processes• Data• Techniques• Inventions (whether patentable or not)• Works of authorship• Business and product development plans• Modifications to or for the workplace

I found an article in a magazine that I think would be helpful to other people in my department. Can I make a copy of this and pass it out to staff?

The “fair use” exception may allow you to make a copy of the article or publication for educational purposes. Before making a copy of the article, please check with the magazine regarding copyright permission. Most magazines include a phone number to call for photocopying. If you are still uncertain, call the UCHealth Legal Department or Compliance Department.

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Conflicts of interest.UCHealth team members must avoid relationships and activities that could interfere with their ability to conduct business fairly. If you have outside activities or personal interests that influence or appear to influence your ability to make objective decisions on the job, a conflict of interest may exist. As a general rule, a supervisor should not directly or indirectly supervise, evaluate or be involved in the employment of any employee with whom they have a personal or business relationship. Any actual or potential conflict of interest must be disclosed as quickly as is reasonably practical to your supervisor or manager or to the Compliance Department.

Using UCHealth information, resources or company time for anything that brings personal or financial gain to you or your family may be a conflict of interest. If you have another job or plan on having one elsewhere, you should tell your supervisor or manager the name of your outside employer and the type of job to determine if a conflict exists.

Gifts, gratuities and entertainment.UCHealth team members will not give or accept business gifts or favors that represent, or could be thought to represent, unfair business incentives; violate laws, regulations or policies of UCHealth; or could cause embarrassment to or reflect negatively upon the reputation of UCHealth. Free vendor-sponsored training or education, including travel and lodging, may only be accepted when the business value to UCHealth outweighs the entertainment value of the training event. You must get the appropriate approvals from your Senior Manager and the Compliance Department before participating in such training or education.

UCHealth team members are prohibited from accepting cash or cash equivalents (including gift certificates and lottery tickets) from patients, existing and potential vendors or referral sources. If a patient or guest offers you cash or a substantial gift, attempt to return the gift. If you are unable to do so, please contact your hospital's foundation.

UCHealth team members must never provide gifts, entertainment, meals or anything else of value to any employee of the of the federal government.

A local vendor has offered to pay for some of our staff to attend a conference to learn about a new product. They will pay all travel expenses. Is this a conflict of interest?

Accepting this offer could be construed as accepting a gift of greater than nominal value or an inducement to conduct business with that vendor and should not be accepted. If UCHealth feels that learning about the product is worthwhile, the health system may approve paying for your staff to attend. When in doubt, discuss the situation with your director or the Compliance Department.

I have been asked to give a presentation to a professional group on a day during my work time. They have offered me an honorarium. Can I accept an honorarium?

You must decline such payment or submit it to UCHealth because you are speaking during your regularly scheduled work hours. You may accept honorariums only if (a) the speaking engagement is unrelated to your employment role (past or present) and you are not speaking on behalf of UCHealth; and (b) you prepare and file the presentation on your own time or during approved PTO time. Make sure you get prior approval from your department supervisor or director.

I work in our emergency department and I am considering starting a business selling resuscitative equipment over the internet. Is this considered a conflict of interest?

This type of second employment may be a conflict of interest. You should consult your department director and/or Human Resources for clarification before proceeding.

I have a friend who works at another hospital and we often get together and share stories about work. Is this wrong?

No. As long as the stories are general in nature. However, certain types of information would be inappropriate for discussion. For example, sharing of information that would breach patient confidentiality or that is proprietary to UCHealth and its entities (e.g., prices, costs, terms, business policies and plans, etc.). This type of information sharing is unethical and, in some cases, illegal. Such discussions must be avoided.

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Contractor relationships.UCHealth is committed to maintaining positive working relationships with contractors, sub-contractors and vendors. We select vendors, contractors and sub-contractors based on clinical and business needs, evaluating quality, price, performance history and contracts. Our relationships with these companies will be impartial and fair and will follow the relevant health system policies.

Confidential information about contracts with contractors, subcontractors and vendors will not be released to any third party without permission, unless required by law.

Community activity: Participation on community boards.UCHealth strongly encourages UCHealth team members to be involved in the communities we serve. This includes serving on boards of directors of other organizations. If you would like to serve on a board for an organization whose interests may conflict with UCHealth, you must first get approval from your supervisor or manager. If you and/or your supervisor or manager need help with the decision, contact the Compliance Department .

Political activities.Everyone who works for UCHealth is an employee of University of Colorado Hospital Authority (UCHA) and UCHA is restricted by state law from endorsing, financially supporting or campaigning for candidates for public office or supporting or opposing ballot initiatives, referendums or recall elections. These restrictions also apply to all UCHA employees—who therefore are prohibited from actively engaging in any campaign or related activity during normal work hours and from using any UCHA resources or equipment (such as copy machines, computers, email) to participate in a campaign, ballot initiative or recall.

I understand that UCHealth does not endorse political candidates or parties, but why does the hospital sometimes endorse ballot issues or other legislative efforts?

In order to remain tax-exempt, UCHealth must refrain from endorsing political parties or candidates, but it is perfectly legal and appropriate for the health system to lend support to issues or efforts that promote positive outcomes for our patients and patients’ health and to oppose efforts that do not.

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Tax-exempt status.UCHealth is a tax-exempt non-profit organization. UCHealth is not required to pay taxes under the Internal Revenue Code but is subject to very specific laws and regulations in order to maintain its tax-exempt status. We must utilize our resources primarily to promote UCHealth’s mission rather than to benefit the personal interests of any one individual or group of individuals.

Employment laws.UCHealth, supported by its CEO, recognizes and appreciates the rich array of talents and perspectives that a diverse staff offers our organization and institutions. UCHealth and University of Colorado Hospital Authority (the sole employer of all staff within UCHealth) is proud to be an equal opportunity/affirmative action employer that takes deliberate steps to recruit, accommodate and maintain a diverse workforce. If you need information or have questions about employment issues, please contact the UCHealth Human Resources Department. If you suspect a violation of employment laws, you are encouraged to report your concern to your supervisor, manager, the Human Resources Department, the Compliance Department, the Integrity Helpline, the Colorado Department of Law Civil Rights Division and/or the United States Equal Employment Opportunity Commission. See specific policies for more detail.

Workplace environment.UCHealth strives to maintain a safe, healthy and efficient environment that is free from any form of harassment or threatening behavior. Harassment and violence are strictly prohibited (which is described in more detail in UCHealth and institutional human resources policies). Team members are expected to treat each other with respect through courteous communication and professional demeanor. Workplace violence may include robbery and other commercial crimes, stalking, inappropriate or unwelcome physical contact, threats, terrorism and hate crimes. UCHealth team members may not have firearms, weapons, explosive devices or other dangerous materials on UCHealth premises except for permitted concealed weapons as permitted by state law. UCHealth team members who see or experience harassment or violence should report it to their supervisor or manager, Human Resources, any senior manager or the Compliance Department, or contact the Integrity Helpline or Security. All UCHealth team members have the right not to be subjected to discrimination as described in the Equal Employment and Anti-Discrimination Statement as well as the Americans with Disabilities Act policy.

I have worked with some of the people in my department for many years. They are always joking with me, but sometimes their comments make me feel uncomfortable. As long as their statements do not threaten my job, then their statements are not sexual harassment, right?

Whether or not someone’s actions meet the legal definition of sexual harassment, you should not be subjected to any behavior that makes you uncomfortable or that you feel is inappropriate on the job. You should report the actions immediately to your supervisor.

I work in a clinic where the father of one of my patients has been using abusive language with me over the past two visits. I don’t feel like I should have to tolerate that, but how can I say anything since good customer service is so important?

While good customer service should be foremost in all of our minds, no one should have to tolerate abusive language from our customers. If you feel uncomfortable saying anything to the parent, you may let your supervisor or the physician know and he/she will handle this situation. The hospitals and clinics have patient representatives who can also help with difficult issues.

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Medical staff compliance and relations.Medical staff members are expected to comply with all federal and state laws along with:

• Provisions of medical staff bylaws and rules and regulations of the institution(s) at which they’re credentialed.

• All applicable Joint Commission Standards.• The UCHealth Code of Conduct.• Organizational policies.

Any violations of these standards must be reported to the appropriate Chief Medical Officer or the compliance department. Medical staff at UCHealth institutions are expected to act ethically and with integrity.

It is the policy of UCHealth that all individuals be treated courteously and with dignity and respect. All UCHealth team members, including the medical staff at UCHealth Institutions, are required to conduct themselves in an appropriate manner and to avoid conduct that:

• Affects the ability of others to do their jobs.• Makes others uncomfortable or causes disruption.• Interferes with an individual’s ability to practice competently.• Has or could have a negative effect on patient care or safety.• Constitutes harassment or abusive personal behavior.

Every time Dr. Pushback is on duty, I do everything I can to avoid calling him with a question. Last time I called, he yelled at me and said, “I can’t believe you’re calling me about that! Did you even pass your boards?” I’m afraid to report this, because this physician will get me fired. What should I do?

An individual who feels they have been the victim of any type of harassment or inappropriate conduct must report the conduct to their supervisor, any supervisor, a member of the Human Resources Department or the Integrity Helpline. An individual who feels they have been the victim or harassment of inappropriate conduct by a member of the medical staff may also report their allegation to the applicable Medical Staff Office. Anonymous reports may be made to the toll-free Integrity Helpline (1.855.824.6287). All reports of disruptive behavior will be investigated. The reporting individual will be notified when the investigation is complete, and appropriate action will be taken as a result of the investigation. No disciplinary action or retaliation will be taken against an individual for reporting in good faith a perceived issue, problem, concern or violation.

We have a new physician joining our practice on May 1. When do we need to begin the credentialing and privileging process so that she can see patients at our facilities?

The credentialing process should begin as soon as possible. Please contact your local Medical Staff Office to get details for the entities at which the physician in question will practice to ensure there is not a delay.

How long is our new physician’s appointment valid once we’ve completed the initial credentialing and privileging process?

Joint Commission standards require that all Medical Staff be reappointed (i.e., re-credentialed) every two years.

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Drug- and alcohol-free workplace.UCHealth prohibits any team member from reporting for or being at work with any detectable amount of alcohol, drugs or controlled substances (or their metabolites) in their system. It may be appropriate to have limited alcohol at an approved UCHealth function. See system policy on alcoholic beverages for approval process.

Sometimes it may be necessary for team members to use drugs prescribed by physicians or other qualified providers. Such drugs must be used following the prescribed instructions and for the intended purpose. UCHealth has the right to decide if team members using prescription drugs are fit to perform their tasks. See UCHealth Alcohol and Drug Free Workplace policy for specific actions to take.

At work, you may have access to drugs and controlled substances. All drugs and controlled substances must be handled carefully and in strict compliance with all laws, policies and regulations. If you suspect that prescription drugs or controlled substances are being taken from your department or misused, you must immediately notify your manager and contact Risk Management.

Environmental health and safety.UCHealth is committed to obeying all environmental laws and regulations that apply to our business. We are also committed to providing a healthy and safe environment for patients, guests and UCHealth team members. Smoking, the use of any tobacco products and the use of electronic cigarettes is prohibited in or on all UCHealth properties including grounds, parking lots, parking structures and sidewalks within property boundaries. UCHealth team members are encouraged to communicate this policy with courtesy to patients and families.

UCHealth team members are expected to be free from the smell of smoke.

If you think an environmental law, rule, regulation or UCHealth policy is being violated, ask yourfacility’s Environmental Health and Safety Office or the Compliance Department for help.

Does UCHealth conduct random drug testing?

UCHealth may perform random drug testing on all safety-sensitive positions. Drug testing is also conducted on all prospective employees. If the prospective employee tests positive for prohibited drugs, they will not be offered a position. If the position has been offered and the new employee fails a drug test, the job offer will not be honored.

If a supervisor or manager has reason to suspect a UCHealth team member is under the influence of drugs or alcohol while at work or on UCHealth premises, the team member may be required to submit to an alcohol or drug test, or may be subject to a search. Employees testing positive or found to be in possession of alcohol or illegal substances may be referred to the Employee Assistance Program and/or receive disciplinary action. This is a condition of employment, and failure to comply with these requests is grounds for corrective action up to and including termination.

UCHealth is required to adhere to various federal, state and local laws and regulations regarding alcohol and drug use. UCHealth also has a vital interest in maintaining a safe, healthy and efficient environment for its employees and the public. Being under the influence of, subject to the effects of or impaired by alcohol or drugs while on the job may pose serious safety and health risks to the user, the user’s coworkers and the public. Additionally, the possession, use or sale of an illegal drug in the workplace may pose an unacceptable risk to the safe, healthy and efficient operation of UCHealth.

I have seen a certain person taking medications that were intended for patients. I believe the medications may have been narcotics because I have seen the same person doing this more than once. I am afraid of reporting this because the person will know who has reported it. Do you have any advice?

The person who is taking medications intended for patients must be reported. We do not tolerate this behavior. If the UCHealth team member has a drug problem, we can assist in seeking help. We owe it to our patients to always provide the best possible care. This can’t be guaranteed if UCHealth team members aren’t reporting violations. If you have any concerns about reporting to your immediate supervisor or director, you should consider calling the Integrity Helpline.

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Marketing.Any marketing program developed and implemented by UCHealth to the community at large will abide by UCHealth’s ethical standards. Marketing programs will reflect truth in advertising and will factually represent those services and programs being advertised. UCHealth may use advertising to inform the community of the availability and the value of our services and products and to inform the public of UCHealth’s views on public policy issues related to health care. UCHealth is perceived by the community as a reliable, authoritative source of information about medical care and the health care industry. We should remain mindful of the trust placed in us by the public and strive to provide accurate, balanced information. Advertisements that make health or safety claims must be supported by tests or studies approved by experts in the appropriate field. Advertisements must be fair. Any immoral, unethical, unscrupulous behaviors found in an organization’s promotions or advertisements may be a violation of the law.

Any promotional activity, including marketing, physician relations and public relations endeavors related to UCHealth, will be based upon actual programs, services and operations and will be presented truthfully. All activities that represent the health system will be presented to the public in accordance with ethical and acceptable business practices.

Social media.When using online social media tools, team members may be subject to aspects of this Code of Conduct, their duty of confidentiality, UCHealth policies and procedures and/or Standards of Excellence. Consequently, appropriate professional behavior is always expected. Team members shall not engage in personal, abusive attacks on fellow team members or patients via social media. Posting patients’ protected health information (whether on or off the clock) is strictly prohibited and is a violation of HIPAA.

Our department is putting together an outreach program that we believe would be of interest to the community. Can I call the newspaper and give them the details?

No. All external or internal communications must be coordinated through the Marketing and Public Relations (PR) Department. All announcements to the public about UCHealth programs must be handled by PR and the media team. Some other activities that you would want to discuss with Marketing and Public Relations include:

• Any paid advertisement or development of campaigns to increase market share for your program among patients and consumers.

• Participation in an interview with news media or responding to a reporter’s questions.

• Assistance with deciding how to publicize your program.• Development of community outreach programs.

Always make sure the marketing team is aware of any events sponsored by UCHealth so they can ensure that you utilize the logo correctly, adhere to brand and graphic standards, and effectively communicate your message on behalf of UCHealth.

I work in the NICU and have created many close relationships with my patients’ family members. I am friends with many of them on Facebook. If one of those

“friends” asks me for medical advice via Facebook, is it OK for me to answer the question?

Employees should not give medical advice using social media sites (SMS). Encourage patients to contact their health care provider.

I want to create a Facebook or SMS page on behalf of my department, unit or group. Is that OK?

Contact the marketing team prior to creating any SMS sites and pages. All SMS pages must be approved by the UCHealth Marketing and Public Relations Department prior to being posted.

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Interaction with the government.If you are contacted by a government agency or representative, notify your immediate supervisor, the Compliance Department and/or the Legal Office. It is important that we are honest and open with the government and its representatives, and provide government inspectors with complete and accurate information. UCHealth team members must not hide, modify or destroy documents, lie or make false statements.

Getting help and reporting violations.When you have ethics or compliance questions or need more information, feel free to contact your supervisor or manager, the Human Resources Department or the Compliance Department. You may also read the health system policies for more detailed information. Ethics and compliance concerns will be kept confidential whenever possible, though there are instances such as an official investigation, patient or staff safety, etc., where we are not able to maintain confidentiality.

We have implemented a confidential, external Integrity Helpline to allow you to present an ethics or compliance concern anonymously. The helpline may be used to report possible violations of this Code of Conduct, the Ethics and Compliance Program, health system policies and procedures and other laws and regulations.

Every UCHealth team member must report suspected violations of the Code of Conduct to their supervisor or manager, senior manager, the Compliance Department or the Integrity Helpline. We will notify you if it becomes necessary to reveal your identity in an official investigation.

UCHealth protects all workforce members against retaliation for reporting Code of Conduct violations or participating in investigations. Penalties for retaliatory behavior can be severe.

How to report a concern.UCHealth suggests following the established leadership chain when reporting issues or concerns. An open door policy is the best policy to have when addressing concerns, therefore, as much as it is within your ability to do so, always first report concerns to your immediate supervisor or manager. When reporting, please attempt to follow the recommended reporting structure:

• Immediate supervisor or manager• Department director• Department vice president

Disregarding the chain of command may affect the morale of staff and management and can create an atmosphere of distrust. If you are uncomfortable reporting your concern to any level in the chain, direct your concern to the next level of leadership. If you do not feel comfortable approaching the individuals above, one of the following resources may be contacted (see contact information on page 22):

• Director of Compliance and Privacy • Chief Compliance Officer • Human Resources

If you wish to report anonymously: Integrity Helpline—1.855.824.6287—available 24/7

Accessing health system policies.UCHealth policies are available on The Source. For example, you can find a copy of the Compliance Plan and this Code of Conduct on the intranet. Check with your supervisor or manager or Information Services for more information on accessing the intranet from your work area.

What should I do if an investigator asks to talk to me about the activities of my department?

You have the right to speak with a government investigator and UCHealth will not infringe upon this right. You should also notify your immediate supervisor, the Compliance Department and/or the Legal Department as soon as possible. You should be aware that you may have the right to consult with a personal attorney before answering any questions and to possibly have an attorney present during questioning.

I have been with UCHealth for a long time. Even though the helpline is confidential, could the operators recognize my voice?

An outside service is used to answer all calls made to the helpline number. The person answering the phone is not a UCHealth team member.

I don’t want to get someone fired; I just want fair treatment in my department. Should I call the Integrity Helpline, or is there a better way to resolve the problem?

Always try to resolve an issue first with your immediate supervisor or director. If you cannot do this successfully or if you do not feel comfortable talking to her/him, you may call the Compliance Department directly for any situation that you feel should be investigated.

The Integrity Helpline has also been established to allow confidential, anonymous reporting. You will receive a tracking number which allows you to call back to the helpline at a later date to obtain an update on progress made toward resolving the issue you reported.

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Compliance Program.The Compliance Department, along with the Compliance Committees, exists to support UCHealth’s commitment to ethics and compliance. The Compliance Program is implemented and enforced by the Chief Compliance Officer, Chief Privacy Officer, Directors of Compliance and Privacy (DCPs) and compliance support staff.

Compliance Department phone numbers.VP, Chief Compliance Officer, Chief Audit Executive303.752.8235

Chief Privacy Officer970.237.7022

Director of Compliance and Privacy—Metro Denver303.752.8246

Director of Compliance and Privacy—Northern Colorado970.237.7021

Director of Compliance and Privacy—Colorado Springs719.365.2309

Director of Compliance and Privacy—UCHMG719.365.2790

HR Service Center phone numbers.Northern Colorado970.495.7800

Metro Denver720.848.6800

Colorado Springs719.365.5114

uchealth.org

17-COMP-1904

http://uchealth.org

Documents

Code of Conduct - UCHealth · No. Our actions must always be guided by our Standards of Excellence. We serve others with courtesy, compassion and sensitivity. Patients are often frightened,